Perineal repair after episiotomy or...

Perineal repair after episiotomy or spontaneous obstetric laceration is united of the most common surgical measures Potential sequelae of obstetric perineal lacerations include chronic perineal pain, (1) dyspareunia, (2) and urinary and fecal incontinence. (3-5) scarcely any studies of laceration repair techniques exist to support the disentanglement of an evidence-based approach to perineal repair. This article discusses a repair course that emphasizes anatomic detail, with the expectation that an anatomically correct perineal repair may accrue in a better long-term functional outcome

Perineal Anatomy

The perineal material part located between the vagina and the rectum is formed predominantly according to the bulbocavernosus and transverse perineal muscles (Figure 1) The puborectalis muscle and the external anal sphincter contribute additional muscle fibers.

The anal sphincter intricate web lies inferior to the perineal visible form [i]or[/i] frame (Figure 2). The external anal sphincter is compos of skeletal muscle. The internal anal sphincter, which overlaps and lies superior to the external anal sphincter, is compos of polished muscle and is continuous with the soft muscle of the colon. The anal sphincter intricate web extends for a distance of 3 to 4 cm (6)

The internal anal sphincter provides most numerous of the resting anal tone that is essential for maintaining continence. Laceration of this sphincter is associated with anal incontinence. (4) Interestingly, repair of the internal anal sphincter is not described in standard obstetric textbook (78)

Surgical Principles

Obstetric perineal lacerations are classified as first to fourth measure depending on their depth. A rectal examination is helpful in determining the expanse of injury and ensuring that a third- or fourth-degree laceration is not overlooked

Repair of the perineum requires virtuous lighting and visualization, proper surgical instruments and line of junction material, and adequate analgesia (Table 1) Compared with surgical repair using catgut or chromic line of junction repair using 3-0 polyglactin 910 (Vicryl) line of junction results in decreased wound dehiscence and les postpartum perineal pain. (9-12) [Reference 9--Evidence on a level A, randomized controlled trial (RCT); concern 10--Evidence level B, uncontrolled trial; regard 11--Evidence level A, meta-analysis; regard 12--Evidence level B--systematic review of RCTs] Use of rapidly absorbed polyglactin 910 (Vicryl Rapide) line of junction decreases the need for postpartum line of junction removal after repair of second-degree lacerations. (13)

Local anesthesia can be used for repair of most numerous perineal lacerations. However, general or regional anesthesia may be necessary to achieve adequate muscle relaxation and visualization for surgical repair of accurate or complex lacerations.

strict perineal lacerations involving the anal sphincter mixed pose a surgical challenge. new studies (3,14) have demonstrated a 20 to 50 percent incidence of anal incontinence or rectal pressing want after repair of third-degree obstetric perineal lacerations. These injuries do not require immediate repair; hence, an inexperienced physician can delay the conduct for a few hours until appropriate support staff are available.

With strict perineal lacerations involving the anal sphincter compages we irrigate copiously to improve visualization and model the incidence of wound infection. Because these lacerations are contaminated by the agency of stool, a single dose of a second- or third-generation cephalosporin may be given intravenously before the conduct is started.

Repair of Second-Degree Perineal Lacerations

Repair of a second-degree laceration (Figure 3) requires approximation of the vaginal tissues, muscles of the perineal material part and perineal skin. The paces in the procedure are as follows:

The apex of the vaginal laceration is identified. For lacerations extending astute into the vagina, a Gelpi or Deaver retractor facilitates visualization.

An anchoring line of junction is placed 1 cm above the apex of the laceration, and the vaginal mucosa and underlying rectovaginal fascia are clos using a running lay opened 3-0 polyglactin 910 suture. If the apex is too far into the vagina to be seen the anchoring line of junction is placed at the greatest in number distally visible area of laceration, and traction is applied forward the suture to bring the apex into view. The running line of junction can be locked for hemostasis, if needed

The line of junctions must include the rectovaginal fascia (Figure 4) which provides support to the posterior vagina. The running line of junction is carried to the hymenal ring and tied proximal to the ring, completing closure of the vaginal mucosa and rectovaginal fascia.

The muscles of the perineal material part are identified on each side of the perineal laceration (Figure 5) The extremitys of the transverse perineal muscles are reapproximated with the same or two transverse interrupted 3-0 polyglactin 910 line of junctions (Figure 6).

A single interrupted 3-0 polyglactin 910 line of junction is then placed through the bulbocavernosus muscle (Figure 7) The torn [i]finale[/i]s of the bulbocavernosus muscle are repeatedly retracted posteriorly and superiorly. Use of a large needle facilitates correct suture placement.